Left atrial strain in heart failure with preserved ejection fraction.

BACKGROUND: Heart failure with preserved ejection fraction (HFpEF) is a syndrome in which patients have symptoms and signs of heart failure but preserved ejection fraction. Left atrial (LA) volume and function are known to be impaired in these patients. Two-dimensional speckle-tracking echocardiography (2D-STE) has recently enabled the quantification of LA deformation dynamics. In this study, we evaluated the use of 2D-STE for the diagnosis of HFpEF. PATIENTS AND METHODS: The study included 83 patients with suspected HFpEF. Patients were divided into two groups after HFpEF had been diagnosed according to current guidelines. Parameters of diastolic dysfunction were evaluated, including left ventricular mass index (LVMI), LA volume index (LAVI), E/A ratio, deceleration time (DT), E/E', and STE parameters such as global longitudinal LA strain during ventricular systole (GLAs-res) and strain during late diastole (GLAs-pump). RESULTS: The values of BNP, LVMI, DT, LAVI, and GLAs-res were significantly different between the two groups. In univariate analysis, a strong negative correlation was seen between GLAs-res and BNP (r = -0.567, p < 0.001) as well as between GLAs-res and DT (r = -0.665, p < 0.001), while a moderate negative correlation was found between GLAs-res and LVMI (r = -0.458, p < 0.001) and GLAs-res and LAVI (r = -0.316, p = 0.004). In logistic regression analysis, GLAs-res (p = 0.049, OR = 0.71, 95 % CI = 0.451-0.99), BNP (p = 0.025, OR = 1.08, 95 % CI = 1.01-1.14), and LAVI (p = 0.042, OR = 1.59, 95 % CI = 1.02-2.48) were found to be independent predictors of HFpEF. CONCLUSION: LA function as assessed by 2D-STE is impaired in patients with HFpEF. A GLAs-res value of < 17.5 % can be useful for the diagnosis of HFpEF.

Frequency of silent myocardial ischemia in type 2 diabetic patients and the relation with poor glycemic control.

The aim of the study was to investigate the frequency of silent myocardial ischemia in type 2 diabetic patients without any clinical or laboratory findings of myocardial ischemia and to examine the related factors for silent myocardial ischemia. A total of 116 type 2 diabetic patients (82 women) with a disease duration of 5-20 years were included in the study. All patients underwent stress and resting myocardial perfusion single-photon emission computed tomographic (SPECT) study with (99m)Tc-MIBI. Coronary angiography was performed in patients with ischemia established at myocardial perfusion SPECT. Ischemia was determined in 18 (15.5%) patients by myocardial perfusion SPECT. Coronary angiography performed in 17 of these patients confirmed coronary stenosis >50% in 11 patients. Thus, the prevalence of silent myocardial ischemia was 9.6%. Significant relations were found between silent myocardial ischemia and male sex, high HbA(1C) level and retinopathy. Type 2 diabetic patients (especially men) with poorly controlled diabetes mellitus or retinopathy should be screened for silent myocardial ischemia.

Incessant monomorphic ventricular tachycardia during febrile illness in a patient with Brugada syndrome: fatal electrical storm.

A 55-year-old male with structurally normal heart presented with sustained monomorphic ventricular tachycardia (VT) and was cardioverted into sinus rhythm revealing a right bundle branch block pattern at baseline electrocardiography. Sustained monomorphic and nonsustained polymorphic VT were reproducibly inducible during electrophysiological study. During the diagnostic workup, the patient experienced fever due to hospital based pneumonia, which unmasked typical ST segment changes of Brugada syndrome. In the intensive care unit, fever became intractable leading to incessant monomorphic VT, which was resistant to all medical manoeuvers resulting in the patient's death.

The significance of the percentage of the defect size in spina bifida cystica in determination of the surgical technique.

AIM: Our aim was to classify meningoceles and meningomyeloceles in terms of defect area as a percentage of the thoracolumbar region to make it possible to select the surgical technique accordingly. MATERIALS AND METHODS: Thirty-two cases were included in the study program. Any defect smaller than 8% of the thoracolumbar region was primarily sutured and classed as grade 1. RESULTS: The defects that it was not possible to handle with primary suture because of the broad base and thereby closed with muscle-skin flaps were those occupying more than 8% of the thoracolumbar region and these were classed as grade 2. It was not possible to perform primary repair of any defect occupying more than 8% of the thoracolumbar area. CONCLUSION: The use of combined latissimus dorsi+gluteus maximus muscle-skin flaps was found to be safe in broad-based meningomyelocele defects, as they provide wider closures and permanent bolstering of the meningomyelocele defect, thus protecting the region against multiple trauma.

Medroxyprogesterone acetate, enoxaparin and pentoxyfylline cause alterations in lipid peroxidation, paraoxonase (PON1) activities and homocysteine levels in the acute oxidative stress in an experimental model of spinal cord injury.

BACKGROUND: Effects of medroxyprogesterone acetate, enoxaparin and pentoxyfylline on lipid peroxidation, antioxidant defence system, paraoxonase activities, and homocysteine levels in an experimental model of spinal cord injury were investigated. METHOD: Sixty-three male albino Wistar rats were anaesthetized by 400 mg/kg chloral hydrate and divided into 5 groups. G1 (n 7) = control group provided the baseline levels. G2-G5 underwent T3-6 total laminectomies and spinal cord injuries by clip compression at T4-5 levels. Medications were applied to G3-G5 right after the injury. Hence, G2 constituted laminectomy + injury (lam+I); G3 = lam + I + medroxyprogesterone acetate (MPA), G4 = lam + I + enoxaparin (E), and G5 = lam+I+pentoxyfylline (P) groups. Animals were decapitated either at the 1st or 4th hour after injury. Tissue and blood malonyldialdehyde (MDA) and plasma homocysteine and erythrocyte superoxide dismutase (SOD) levels, and erythrocyte glutathione peroxidase (GSH-Px) and plasma paraoxonase (PON1) activities were assayed. SPSS 9.0 program was used for statistical analysis and graphics. Intergroup comparisons were made by Bonferroni corrected Mann Whitney U test ( P<0.025), and intragroups comparisons by Wilcoxon Rank test ( P<0.03). FINDINGS: In intergroup comparison, G1-G2, G1-G3, G1-G5, G2-G3, G2-G4, and G4-5 groups differed from each other for all parameters ( P<0.025, MWU) except for G4-G5 4th hour MDA levels. G1-G4 was similar for all 1st hour parameters ( P>0.025, MWU), but different for 4th hour ( P<0.025, MWU) except for GSH-Px and SOD levels. For G2-G5, all parameters for 1st and 4th hour were similar except for 4th PON1, Hcy and SOD levels. For G3-G4, all 1st hour parameters were different from each other ( P<0.025, MWU); whereas all 4th hour parameters were similar except for SOD level. For G3-G5, all parameters at 1st and 4th hour were similar except for 4th hour GSH-Px, PON1, and Hcy. In intragroup comparison, all parameters differed from each other at all times (P<0.03, WRT) except for 1st hour G4 MDA, Hcy and SOD levels compared to basal levels. INTERPRETATION: In injury groups, plasma Hcy levels decreased and PON1 activities increased as erythrocyte SOD level and GSH-Px activities decreased in parallel to increases of tissue and blood MDA levels. These changes were relatively suppressed by MPA, enoxaparin and pentoxyfylline administrations at varying degrees. Enoxaparin was the most powerful agent, particularly at 1st hour. MPA was also effective, particularly at 4th hour. Pentoxyfylline despite having slight effect at 4th hour, was not effective according to both control and injury groups. Enoxaparin and MPA can be used in the treatment of spinal cord injuries. PON1 and Hcy are helpful in monitoring the antioxidant defence system as well as SOD and GSH-Px, both in injury and medically treated groups.

The effect of lipoprotein-a on thrombolytic therapy and spontaneous reperfusion in acute myocardial infarction. A comparative study.

BACKGROUND: To evaluate the role of serum lipoprotein-a (Lp-a) levels on the success of thrombolytic therapy (TT) in patients with acute myocardial infarction (MI). PATIENTS: 56 patients randomly allocated into 2 groups (A and B) with an approximately 1 to 2 ratio. Group A consisted of 18 patients who received 1,5 million IU streptokinase. Group B: 38 patients receiving 100 mg t-PA totally and Group C: 22 patients who did not received any TT as controls. All patients had undergone coronary angiography in the first 7 days and the degree of TIMI flow was determined in the infarct related artery with TIMI-0 and I being considered as unsuccessful perfusion, whereas TIMI-II and III as successful. Lp-a level gs;30 mg/dl was considered as high Lp-a level. RESULTS: Patency rates were similar in Group A and B, in cases with high or low Lp-a levels (p>0.05 for both). In Group C patency rate was found significantly higher in patients with high Lp-a level compared to patients with low Lp-a (p<0.01). Lp-a level in Group C was similar with Group A and B (p>0.05). The time interval for coronary angiography was similar in all groups (p>0.05 for all). CONCLUSIONS: Lp-a level does not effect the reperfusion outcome of TT in patients with MI. However in those patients who not received TT, spontaneous reperfusion rate was found significantly higher in patients with low Lp-a level compared to those with high Lp-a level.

Estimation of left ventricular end-diastolic pressure by color M-mode Doppler echocardiography and tissue Doppler imaging.

OBJECTIVES: The aim of this study was to estimate left ventricular end-diastolic pressure (LVEDP) noninvasively by tissue Doppler imaging and color M-mode echocardiography. MATERIAL AND METHODS: We studied 3 groups of patients who were proven by angiography to be free of significant coronary artery lesions (<40% stenosis) with an LVEDP < 10 mm Hg (group A: n = 24; 16 men, 18 women; mean age +/- SD = 55 +/- 13 years), an LVEDP of 10 to 15 mm Hg (group B: n = 21; 17 men, 4 women; mean age 56 +/- 11 years), or an LVEDP > 15 mm Hg (group C: n = 35; 20 men, 15 women; mean age 58 +/- 9 years). Tissue Doppler imaging of the lateral mitral annulus and color M-mode imaging of the mitral valve in the apical 4-chamber view were obtained with an echocardiographic system. Early and late diastolic velocities (Em and Am, respectively), Em deceleration time (EmDT), Am time (Am-t), and mitral propagation velocity time delay (VpDT) were measured in each patient. RESULTS: In group A, sensitivity and specificity for EmDT < or = 100 ms, Am-t < or = 90 ms, Em/Am > or = 1, and VpDT < or = 45 ms were found to be 0.57 and 0.89, 0.66 and 0.88, 0.86 and 0.92, and 0.73 and 0.89, respectively. In group B, sensitivity and specificity for EmDT 100 to 120 ms, Am-t 90 to 110 ms, Em/Am 1 to 0.5, and VpDT 45 to 60 ms were found to be 0.57 and 0.84, 0.69 and 0.82, 0.66 and 0.75, and 0.55 and 0.83, respectively. In group C, sensitivity and specificity for EmDT > 120 ms, Am-t > 110 ms, Em/Am < 0.5, and VpDT > 60 ms were found to be 0.88 and 0.81, 0.71 and 0.80, 0.86 and 0.72, and 0.78 and 0.86, respectively. CONCLUSION: The EmDT, Am-t, Em/Am, and VpDT measurements obtained noninvasively by left ventricular tissue Doppler imaging and mitral flow propagation velocity were found to be useful in the estimation of LVEDP.

Spontaneous cerebrospinal fluid rhinorrhea associated with chronic renal failure--case report.

A 39-year-old woman was admitted with complaints of headache and nasal discharge on the left for 3 months which was later on proved to be cerebrospinal fluid (CSF). Neurological examination found no abnormalities except bilateral papilledema. Neuroimaging demonstrated enlargement of the lamina cribrosa foramina through which the olfactory nerves pass, as well as empty sella and cerebral cortical atrophy. Bone mineral densitometry showed osteopenia. CSF Ca++ and blood parathyroid hormone levels were elevated. CSF pressure was 280 mmH2O. Bilateral frontal craniotomy was performed to expose the anterior fossa. Foraminal enlargement at the lamina cribrosa was confirmed, and islands of extra-osseous calcifications on the arachnoid membrane were identified. The base of the anterior fossa was repaired intradurally with fascial graft and fibrin glue on both sides. No CSF leakage was noted at 1-year follow up. Spontaneous CSF leakage probably resulted from enlargement of the foramina at the lamina cribrosa due to Ca++ mobilization from bones and pseudotumor cerebri not to the extent of hydrocephalus caused by poor CSF absorption at the arachnoid granulations obliterated by extra-osseous calcareous accumulation.

Primary Ewing's sarcoma of the occipital bone--case report.

A 17-year-old female presented with a very rare case of primary Ewing's sarcoma of the skull involving the occipitotemporal region. Systemic examination found no evidence of metastasis. The tumor was surgically removed, and the patient underwent radiotherapy and chemotherapy. Fourteen months after surgery there has been no recurrence of the tumor. Cranial primary Ewing's tumor has a good prognosis after radical surgery and adjuvant therapy.

Malignant schwannoma of the sciatic nerve originating in a spinal plexiform neurofibroma associated with neurofibromatosis type 1--case report.

A 26-year-old man with neurofibromatosis type 1 (NF1) presented with a giant malignant schwannoma of the sciatic nerve. The differential diagnosis of malignant peripheral nerve sheath tumor (MPNST) was based on clinical, radiological, and histological evidence. The tumor apparently originated in a spinal plexiform neurofibroma. The lesion was resected totally without neural damage to the sciatic nerve. However, the tumor recurred within 2 months. The patient died of unknown factors probably associated with the spinal involvement. MPNST associated with NF1 has a poor prognosis due to recurrence or metastasis despite complete macroscopic removal.

Pulmonary artery thrombi detected by echocardiography in patients with pulmonary hypertension secondary to atrial septal defect.

This report presents three patients with severe pulmonary hypertension secondary to atrial septal defect associated with thrombus and spontaneous echo contrast within the pulmonary artery diagnosed by transthoracic and transoesophageal echocardiography. Clinical and echocardiographic features seem to suggest local thrombus formation within the pulmonary arteries as a direct consequence of pulmonary hypertension rather than venous thromboembolism.

Giant hiatal hernia presenting with stable angina pectoris and syncope--a case report.

A 70-year-old woman with giant hiatal hernia presented with stable angina pectoris and three syncope attacks in the previous 3 months. Chest radiography showed marked cardiomegaly and an air-fluid level at the basal region of the heart. A mixed type large hiatal hernia that distorted the heart was detected in contrast-enhanced computed tomography and esophagogastroduodenography. Postprandial nonsustained ventricular tachycardia was present on 24-hour Holter ECG monitoring. The patient's symptoms were attributed to giant hiatal hernia and improved following surgery.

Investigation of perfusion reserve using 99Tc(m)-MIBI in the lower limbs of diabetic patients.

This study aimed to investigate the microvascular pathology in the lower limbs of diabetic patients without symptoms or findings of peripheral ischaemia by measuring perfusion reserve scintigraphically. It was carried out in 47 female subjects who had no evidence of peripheral arterial disease in their history, physical examination or Doppler ultrasonography. The diabetic group consisted of 25 women (mean age 54.2 +/- 3.54 years) with type II diabetes mellitus of more than 10 years' duration. A control group consisted of 22 healthy non-diabetic women (mean age 50.14 +/- 6.75 years). Each subject flexed their right foot maximally both dorsally and plantar 60 times. In the middle of this exercise, 370 MBq technetium-99m-methoxyisobutylisonitrile (99Tc(m)-MIBI) was injected intravenously. Ten minutes after the injection, a posterior image of both calves was obtained using a gamma camera. Rectangular regions of interest were symmetrically drawn over both calves. The total count in the resting calf was subtracted from the total count in the exercising calf, and the percentage increase, termed the perfusion reserve, was determined. A significant difference was found between the perfusion reserves of the diabetic and control groups (76.04 +/- 12.96% and 95.91 +/- 12.83%, respectively; P<0.001). In conclusion, microvascular pathology may be determined scintigraphically by measuring the perfusion reserve in the lower limb muscles in diabetic patients. This method may also be used to evaluate perfusion abnormalities in other circulatory disorders.

Transesophageal echocardiography assessment of left atrial appendage function in untreated systemic hypertensive patients in sinus rhythm.

To assess left atrial appendage (LAA) function in hypertensive patients without treatment, transesophageal echocardiography (TEE) was performed in 46 hypertensive patients in sinus rhythm, aged 40 to 55 years, and in 16 control subjects (group I) without cardiovascular disease, aged 41 to 54 years. The hypertensive patients were divided into 2 groups according to left ventricular (LV) systolic function: group II, the group with normal LV systolic function (ejection fraction 0.63 +/- 0.08), and group III, the group with LV systolic dysfunction (ejection fraction 0.39 +/- 0.05). The LAA late emptying velocities (EVs) were significantly reduced in the hypertensive subgroups compared with the control group (P <.001), but no significant difference in the LAAEV was found between groups II and III. The LAAEV in the hypertensive patients had a significant negative correlation with diastolic blood pressure, systolic blood pressure, and left atrial (LA) diameter. The maximal LAA areas were significantly larger in the hypertensive subgroups than in the control group (P <.05). No significant difference in LAA maximal area existed between groups II and III. The maximal LAA area in the hypertensive patients had a significant positive correlation with diastolic blood pressure, systolic blood pressure, and LA diameter, but a significant negative correlation with LV ejection fraction. With TEE, LA spontaneous echocardiographic contrast (SEC) was present in 6 (43%) of 14 patients in group III (P <.01) and in 7 (22%) of 32 patients in group II (P <.05). No significant difference in the occurrence of LASEC was found between groups II and III. Left atrial appendage thrombi by TEE were observed in 4 (29%) of 14 patients in group III (P <.05) and in 4 (13%) of 32 patients in group II (P = not significant). No significant difference in the occurrence of LAA thrombus existed between groups II and III. In conclusion, in patients with untreated hypertension, marked elevation of afterload imposed on the left atrium may involve both the left atrium and the LAA, resulting in impairment of LAA function. This condition may worsen with subsequent occurrence of SEC and later, thrombus formation. Therefore assessment of LAA function may be important even in the hypertensive patient in sinus rhythm.

Single-photon emission computed tomographic myocardial perfusion imaging in patients with mitral valve prolapse.

The possibility of exercise-induced myocardial ischemia due to mitral valve prolapse (MVP) in the absence of coronary artery disease was evaluated with single-photon emission computed tomographic analysis using thallium-201 and technetium-99m sestamibi in 72 patients with MVP. Exercise electrocardiography was positive in 5 patients (8%), but single-photon emission computed tomography was found to be normal in all patients, and exercise-induced chest pain, electrocardiographic changes, and arrhythmias were found not to be related to myocardial ischemia in patients with MVP.